final exam Flashcards
Labour and Birth Process pp pt 1
5 P’s of Labour
Passenger
Passageway
Powers - primary and secondary
Position
Psychologic
Passenger
The fetus
-factors affecting labor:
1. size of head, skull bones, fontanels, molding
-presentation: part of fetus that enters the pelvic inlet first and leads the rest of the body through the birth canal
cephalic/vertex, breech, or shoulder
cephalic presentation can be either:
vertex/occiput (full flexion),
sinciput/military (moderate flexion),
brow (partial extension), or
face (poor flexion, complete extension)
lie: longitudinal or vertical
presentation: vertex, breech
reference point: occiput or sinciput
attitude: general flexion
- fetal lie: the relation of the long axis (spine) of the fetus to the long axis (spine) of mom
-longitudinal or vertical - Fetal attitude: the relation of the fetal body parts to one another
-general flexion
-critical measurements of fetal head: biparietal diameter or suboccipitobregmatic
-vertex presentation - 9.5 cm across. chin tucked way in (flexed)
-sinciput presentation - 12 cm across (chin not flexed that much)
-brow presentation - 13.5 cm across (chin lifted up like sniffing)
slide 7 - Fetal position: relationship of a reference point on the presenting part to the 4 quadrants of the mom’s pelvis
-three-part letter abbreviation - fetal station: a measure of the degree of descent of the presenting part of the fetus through the birth canal
- fetal engagement: usually corresponds to 0 station. 0 lines up with the ischial spine. -5 to 5. -5 is up high
Passageway
aka the birth canal
there are 4 types of bony pelvis:
1. gynecoid (true female pelvis, ideal)
-cavity is shallow with a broad, well-curved sacrum, pubic arch forms the right angle, and a 90-degree wide
- Android: (male pelvis) heart-shaped brim
- Anthropoid: oval brim, narrow in the transverse
- Platypelloid: kidney-shaped brim, narrow in anterior-posterior diameter
Powers
Primary powers: contractions
-frequency, duration, intensity
-effacement, dilation
-Ferguson reflex (The second stage begins when the cervix is fully dilated and ends when the baby is born. As pressure on the cervix increases, the Ferguson reflex increases uterine contractions) class def: increased intrauterine pressure put of the descending part of the fetus on the cervix. More pressure with a cephalic, not as much hard SA with a breech. Mom “I need to push”
-contractions start at upper part of uterus, works downwards in waves, with short rest periods between
Secondary powers: bearing down efforts
-Push during a contraction. Synergy.
-valsalva maneuver:
The mother is asked to take a deep breath, hold the breath (closed glottis), and push downward when a contraction starts
Trauma-informed Care: Services provided in ways that recognize the need for physical and emotional safety, as well as choice and control in decisions affecting one’s treatment. Trauma-informed practice is an approach to care, or way of being in the relationship, intending to create an environment where service users do not experience further traumatization or re-traumatization (events that reflect earlier experiences of powerlessness and loss of control). Individuals can make decisions about their treatment needs at a pace that feels safe to them.
Position and Psychologic
Position and mental state of laboring mom
Process of Labor
Labor: process of moving the fetus, placenta, and membranes out of the uterus and through the birth canal
signs of preceding labor:
1. lightening: as head settles into the pelvis, the woman senses greater room aka”dropping”
2. Bloody show: blood-tinged mucous discharge. Associated with the thinning of the cervix. A preliminary sign of labor. (mucous plug)
-the cervix must ripen. Unripe feels like nose cartilage. Ripe cervix feels like lips
-possible rupture of membranes
Onset of labor:
-cannot be ascribed to a single cause
-increasing estrogen, oxytocin, prostaglandins
-progesterone falling (progesterone maintains pregnancy)
-all these working together to start contractions
Stages of labor - 4 stages
Onset of labor:
-cannot be ascribed to a single cause
-increasing estrogen, oxytocin, prostaglandins
-progesterone falling (progesterone maintains pregnancy)
-all these working together to start contractions
(1) FIRST stage:
-latent phase
-active phase
-transition phase
-usually longest stage because cervix must open 10 cm
-from onset of labor to the completion of cervix dilation
-Latent phase- slow descent and slow dilation
-Active phase- real dilation of the cervix
-transition stage
(2) Second stage:
-From fully dilated to baby out
-expulsion of baby
(3) Third stage:
-from birth of baby to complete expulsion of placenta and membranes
-placenta out
(4) Fourth stage:
-2 hours after birth
-stay 1:1 with mom
process of labor cont
Mechanism of labor:
-turns/adjustments/movements necessary in the birth process
-7 cardinal movements of mech. of labor
1. engagement
when fetus engages into the true pelvis.
Can start 2 wks before delivery
-engagement of a pelvic organ to an abdominal organ
- descent
-now in true labor. Contractions and dilation taking place helping descent - flexion
-from pressure of contractions from above and pressure from bottom from resistance from cervix. Flexes head even more - internal rotation
Head rotates into an anterior or posterior position so occipital is under the symphysis pubis - extension
-head is crowning under symphysis pubis - restitution and external rotation
-head turns to side, so body turs as well on the inside
-will see shoulder come out - expulsion
Fetal adaptation
FHR (fetal heart rate): reliable and predictive information about the condition of the fetus related to oxygenation
fetal circulation
fetal respiration
Ductus venosus: connects the UMBILICAL VEIN to the INFERIOR VENA CAVA.
Ductus arteriosus: connects the main PULMONARY ARTERY to the AORTA.
Foramen ovale: anatomical OPENING between the right and left ATRIUM.
Apgar: appearance, pulse, grimace, activity, and respiration
Maternal adaptation
mom exhibits both objective and subjective symptoms
-cardiovascular changes
-resp. changes
-renal changes
-integumentary changes
-musculoskeletal changes
-neuro changes
-gastro changes
-endocrine changes
Key points
Labor and birth are affected by the 5 P’s
passenger, passageway, power, position of mom, psychologic response
because of its size and relative rigidity, the fetal head is a major factor in determining course of birth
Key points 2
****the diameters at the plane of the pelvic inlet, the midpelvis, and the outlet plus the axis of the birth canal determine whether vaginal birth is possible and determines the manner in which the fetus passes down the birth canal
Involuntary contractions act to expel the fetus and placenta during the first stage of labor
-these involuntary contractions are augmented (synergy) by voluntary bearing-down efforts during the second stage
Key points 3
1st stage:
beginning of dilation - cervix fully dilated
2nd stage:
cervix fully dilated - birth of infant
3rd stage:
birth of infant - expulsion of placenta
4th stage:
expulsion of placenta - first 2 hours after birth
Key points 4
The 7 cardinal movements of the mech. of labor are
1. engagement
2. descent
3. flexion
4. internal rotation
5. restitution and external rotation
6. expulsion
Although the events precipitating the onset of labor are unknown, many factors including changes in the uterus, cervix, and pituitary gland are thought to be involved
increase in estrogen, oxytocin, prostaglandins,
decrease in progesterone
key points 5
a healthy fetus with adequate uterofetoplacental circulation is able to compensate for the stress of uterine contractions
As the woman progresses thru labor, various body systems adapt to the birth process
- NonPharm & Pharmaceutical comfort measures (very general, from prenatal lab)
nitrous oxide
opioids: fentanyl, morphine, hydromorphone
positions, ice, ambulation, distraction/relaxation techniques
Maximizing Comfort for the Laboring Woman
lecture I missed
Nonpharmacologic Pain Management
-Relaxing and breathing techniques
Focusing and relaxation
-Effleurage (stroking) and counterpressure
-Touch and massage
Therapeutic touch
-Application of heat and cold
shower/bath
-Acupressure and acupuncture
-Transcutaneous electrical nerve stimulation
-Water therapy (hydrotherapy)
-Intradermal water block: injection of small amounts of sterile water by using a fine needle into 4 locations on the lower back to relieve lower back pain
-Aromatherapy
-Music
-Hypnosis
-Biofeedback
Pharmacologic Pain Management
Sedatives:
relieve anxiety and induce sleep;
-typically used for women in a prolonged latent phase of labor when there is a need to lessen the intensity of the contractions, decrease anxiety, or promote sleep.
Analgesia:
-the alleviation of the sensation of pain or the raising of the threshold for pain perception without loss of consciousness
Nitrous oxide for analgesia
Nitrous oxide mixed with oxygen can be inhaled in a low concentration (50% or less) to provide analgesia during the first and second stages of labor.
Opioid analgesia
Morphine can by injected IV or IM for longer term comfort.
Fentanyl is more common by IV push for immediate and temporary relief.
Anesthesia:
-encompasses analgesia, amnesia, relaxation, and reflex activity
Epidural:
Contraindications to epidural blocks
-Active or anticipated serious maternal hemorrhage
-Maternal hypotension
-Maternal coagulopathy
-Infection at the injection site
-Increased intracranial pressure
-Allergy to the anesthetic drug
-Maternal refusal or inability to cooperate
-Some types of maternal cardiac conditions
*The type of analgesic or anesthetic chosen is determined in part by the stage of labor of the woman and by the method of birth planned.
Use a pain scale and/or coping scale
Care Management for Pharmacologic Interventions
General informed consent
informed consent for anesthesia
timing of administration
preparation for procedures
administration of med
routes: IM, IV, regional (epidural or spinal)
anesthesia
Key points 1
Nonpharma can manage pain/stress alone or in combination with pharma methods
The type of analgesic or anesthetic to be used is determined by maternal and healthcare provider preference, the stage of labor, and the method of birth.
Sedatives may be appropriate for women in prolonged early labor when there is a need to decrease anxiety or promote sleep or therapeutic rest.
key points 2
Naloxone (Narcan) is an opioid/narcotic antagonist that reverses narcotic effects esp. resp depression
nurses must understand meds, their expected effects, potential side effects, and methods of admin
maintenance of maternal fluid balance is essential during spinal and epidural nerve blocks
key points 3
Maternal analgesia or anesthesia can affect neonatal neurobehavioral responses
Epidural anesthesia and analgesia are the most effective avail. pharma pain relief methods for labor
general anesthesia is rarely used for vaginal births but may be used for c-sec or whenever rapid anesthesia is needed in an emergency situation
Opioid agonist analgesics in women with preexisting opioid dependence may cause symptoms of opioid withdrawal/abstience syndrome
Nursing Care of the Family
During Labour and Birth seminar 9
couldnt find so no supp. notes
First Stage of Labour
ASSESSMENT & DIAGNOSIS
Prenatal data
The nurse reviews the prenatal record to identify the woman’s individual needs and risks
Latent phase (up to 3 cm of dilation)
Active phase (4 - 7 cm of dilation)
Transition phase (8 - 10 cm of dilation)
Assessment and nursing diagnosis:
-Determination of whether the woman is in true labor or false labor
Contractions
Cervix
Fetus
Obstetric triage
-woman considered to be in true labor until a qualified provider determines she is not
Admission to the labor unit
includes prenatal data, the interview which includes spontaneous ROM, bloody or pink show, hx of sexual abuse, cultural factors
Physical exam
-general systems, VS, Leopold maneuvers (abd. palpitation), FHR and pattern
-assess uterine contractions:
frequency, duration, intensity, resting tone
(mild/mod/strong)
-vaginal exam
cervical dilation, effacement, fetal descent
-Lab and diagnostic tests
urinalysis from urine specimen
CBC, type and screen, HIV
assessment of amniotic membrane and fluid
all for signs of potential problems
INTERVENTIONS & Plan of Care
-general hygiene
-nutrient and fluid intake (oral and IV)
-Elimination
void at least q2h
catheter care
bowel elimination, intervention
-ambulation and positioning
-supportive care during labor and birth (physical care and comfort measures, emotional support)
-emergency interventions
Second stage of labor
-begins with full 10 cm dilation and complete effacement
-pushing stage
-infant is born
2 phases:
latent: relatively calm with passive descent of infant through birth canal
Active: pushing and urge to bear down. Ferguson reflex: urge to bear down
CARE MANAGEMENT
-preparation for birth
position: supine, semi-recumbent, or lithotomy positions widely used in western society despite evidence that an upright position shortens labor
-bearing down efforts “Valsalva maneuver”
-FHR and pattern
-use of fundal pressure contraindicated
-immediate assessments and care of newborn
Perineal Trauma re: childbirth
Perineal lacerations
first degree:
laceration extends thru skin and vaginal mucous membrane but not the underlying fascia and muscle
Second degree: laceration extends thru the fascia and muscles of the perineal body, but not the anal sphincter
Third degree: laceration involves the external anal sphincter
Fourth degree: laceration extends completely thru the rectal mucosa and both external and internal anal sphincters
-Cervical injuries
-Episiotomy: an incision in the perineum used to enlarge the vaginal outlet. Lacks research to support its benefits
Third Stage of Labor
birth of baby -> expulsion of placenta
-shortest stage of labor (about 10-15 min after birth) * may be problem if >30 min
-sudden gush of dark blood
-lengthening of umbilical cord
-vaginal fullness
-placental exam and disposal according to culture and hospital policy
Fourth stage of Labor
CARE MANAGEMENT
first 2 hours after birth
-Assessment of maternal physical status
-Signs of potential problems
-excessive blood loss, unstable VS, LOC changes
-adaptions to family
Dystocia (dysfunctional labor)
long, difficult, or abnormal labor
-most common indication for a c-sec
-5 P’s affecting labor and birth
(passengers, passageway, power, position, psychologic responses)
Causes:
- POWER: Abnormal uterine activity (alteration in Power)
-Hypertonic uterine dysfunc.:
def: frequent and painful contractions that are ineffective in causing cervical dilation or effacement. Force of contractions are in the midsection of the uterus rather than in the fundus, the uterus is unable to apply downward pressure to push the presenting part against the cervix. Woman are exhausted, and complain of loss of control.
CARE: therapeutic rest, warm bath, shower, narcotic to ensure rest.-Hypotonic uterine dysfunc.:
def: initially makes normal progress into the active phase of stage 1 labor but then the contractions become weak/inefficient/stop altogether
CARE: ambulation, hydrotherapy, ROM, nipple stimulation, oxytocin - Secondary powers - problems bearing down dt large amount of analgesic
- Abnormal labor patterns
-patterns individual to each woman - Precipitous labor
-labor that lasts less than 3 hours from the onset of contractions to the time of birth
-potential complications for mom: uterine rupture, lacerations of birth canal, PPH
-complications for fetus: shoulder dystocia, hypoxia, intracranial trauma
PASSENGER: fetal causes of dystocia:
-anomalies
-cephalopelvic disproportion (CPD) aka fetopelvic disproportion (FPD)
-malposition
malpresentation (breech)
-multifetal pregnancy
PASSENGER: alterations in pelvic structure
-pelvic dystocia:
contractures of pelvic diameters that reduce capacity of bony pelvis, inlet, midpelvis, or outlet
-soft-tissue dystocia:
results from obstruction of the birth passage by an anatomic abnormality other than that of the bony pelvis
POSITION:
-maternal position affects uterine contractions, fetus, and pelvis
PSYCHOLOGIC RESPONSES:
-hormones and neurotransmitters released in response to stress can cause dystocia
-sources of stress and anxiety vary
Obstetric procedures
Induction of labor (IOL)
-the chemical or mechanical initiation of uterine contractions before their spontaneous onset for the purpose of bringing about birth
-labor may be induced either selectively or for indicated reasons
Elective IOL:
-no health indication
-for mom/HCP’s convenience
-risks: risk of c-sec, risk of neonatal morbidity, increased costs
*elective IOL should not be initiated until 39 wks gestation is completed
Bishop’s score for IOL:
-rating system to evaluate inducibility or cervical ripeness
Evaluates:
dilation
effacement
station
cervical consistency
cervical position
cervix station: Station is the measurement of the baby relative to the ischial spines. -5 to +5. 0 is at the ischial spines
Cervical ripening methods for IOL
A) Chemical agents
-prostaglandins to ripen/soften and thin cervix
-oxytocin- see below
B) Physical/mechanical methods
-Amniotomy
“breaking the water” AROM
-catheter insertion thru the intracervical canal and put pressure and stretch the lower uterine segment and cervix
C) Alternative methods
-sex, nipple stimulation, ambulation
Oxytocin induction
-is a hormone naturally produced by posterior pituitary gland
-stimulates uterine contractions and milk let-down
-synthetic oxytocin (Pitocin) may be used either to induce labor or augment labor that is progressing slowly because of inadequate uterine contractions
Augmentation of labor
after labor has started spontaneously and progress is unsatisfactory
stimulation of uterine contractions using oxytocin infusion and amniotomy
ACTIVE MANAGEMENT:
-FHR
-inform mom of procedure
-monitor contraction pattern
-blood pressure, temp, respirations
-intake/output
-observe for nausea, vomiting, headache, hypotension
Obstetric procedures:
Operative vaginal birth
using either forceps or a vacuum extractor
“forceps-assisted birth”
“vacuum-assisted birth”
Obstetric procedures:
Cesarean birth
birth thru a transabdominal incision of the uterus
VBAC: vag. birth after cesarean
TOLAC: trial of labor after cesarean
observing mom in labor for reasonable amount of time (4-6 hours) to assess the safety of vaginal birth
complications and risks
-obesity, age, PET, LGA, rural hospital
anesthesia
preparation
preoperative care
Pet is preeclampsia - high BP, proteinuria, kidney damage
Post anesthesia Recovery
C-sec or after regional anesthesia for vaginal birth needs special attention during recovery period
Post-anesthesia recovery (PAR) unit
Obstetric Emergencies
- Meconium-stained amniotic fluid
-indicates fetus passed stool prior to birth
-dark green
possible causes:
-normal physiologic function of maturity (term or post-term)
-breech presentation
-hypoxia-induced peristalsis
-umbilical cord compression
- Shoulder dystocia
-head is born but shoulder cannot pass under pubic arch
-injuries related to asphyxia, brachial plexus damage, and fractures
-mother’s primary risk stems from excessive blood loss from uterine atony or rupture, lacerations, extension of episiotomy, or endometriosis - Prolapsed umbilical cord
-cord lies below the presenting part of the fetus
-contributing factors include:
-long cord (> 100 cm)
-malpresentation (breech)
-transverse lie
-unengaged presenting part
-cord is at risk of compression= blocking oxygen and blood flow to baby. At onset of fetal distress, emergency c-sec should occur within 12 min - Rupture of the uterus
-rare but serious injury. 1/2000 births
-most frequent cause of uterine rupture occurs during:
-separation of scar tissue of a previous c-sec
-uterine trauma (accidents, surgery)
-congenital uterine anomaly
